1. www.metcardio.org PCI vs. CABG: Review of the evidence and suggestions Giuseppe Biondi Zoccai Division of Cardiology, University of Turin, Turin, Italy Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy 2 nd Fellows’ Meeting, 2-3 October 2009, Bubbio – 2 October 2009, 15:00-15:30

2. www.metcardio.org DISCLOSURE I am a consultant invasive and non- invasive cardiologist who completed fellowship in 2005 I am giving a lecture at a Fellows’ Course

3. www.metcardio.org LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

4. www.metcardio.org LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

5. www.metcardio.org WHO WAS WINNER BETWEEN PCI AND SURGERY?

6. www.metcardio.org ARE THEY ENEMIES OR FRIENDS?

7. www.metcardio.org LET’S LOOK AT THE PAST…

8. www.metcardio.org META-ANALYSIS OF RCTS OF CABG VS. PCI: 5-YEAR-SURVIVAL WITH MVD VS. SVD Bravata et al, Ann Intern Med 2007

9. www.metcardio.org META-ANALYSIS OF RCTS OF CABG VS. PCI: 5-YEAR-SURVIVAL WITH POBA VS. BMS Bravata et al, Ann Intern Med 2007

10. www.metcardio.org HOWEVER, PCI WITH BMS WAS INFERIOR TO CABG FOR THE RISK OF REPEAT PCI/CABG Biondi-Zoccai et al, Ital Heart J 2003

11. www.metcardio.org FURTHER STRATIFICATION FOR DIABETES Hlatky et al, Lancet 2009

12. www.metcardio.org Hlatky et al, Lancet 2009 INCLUDING BARI EXCLUDING BARI FURTHER STRATIFICATION FOR DIABETES

13. www.metcardio.org LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

14. www.metcardio.org WHAT ABOUT THE PRESENT…

15. www.metcardio.org RISK OF MACE AT MID-TERM FOLLOW-UP FOLLOWING PCI WITH DES FOR ULM Biondi-Zoccai et al, Am Heart J 2008

16. www.metcardio.org IMPACT OF LESION LOCATION AND PATIENT RISK FEATURES ON OUTCOMES OF ULM PCI Biondi-Zoccai et al, Am Heart J 2008

17. www.metcardio.org THE SYNTAX TRIAL Serruys et al, New Engl J Med 2009

18. www.metcardio.org THE SYNTAX TRIAL @ 1 YEAR Serruys et al, New Engl J Med 2009

19. www.metcardio.org THE SYNTAX TRIAL @ 2 YEARS

20. www.metcardio.org THE SYNTAX TRIAL @ 2 YEARS

21. www.metcardio.org THE SYNTAX TRIAL @ 2 YEARS

22. www.metcardio.org SYNTAX REGISTRIES @ 1 YEAR PCI REGISTRY (N=192) CABG REGISTRY (N=644)

23. www.metcardio.org CORONARY ARTERY DISEASE IN DIABETICS BARI 2D, New Engl J Med 2009

24. www.metcardio.org CORONARY ARTERY DISEASE IN DIABETICS BARI 2D, New Engl J Med 2009

25. www.metcardio.org BARI 2D, New Engl J Med 2009 Med Rx = Revasc

26. www.metcardio.org BARI 2D, New Engl J Med 2009 Med Rx = PCI Med Rx = PCI Med Rx < CABG Med Rx = CABG

27. www.metcardio.org LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

28. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005

29. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005 THUS CABG IS RECOMMENDED INSTEAD OF PCI IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rate

30. www.metcardio.org MY SURGICAL MUST DOs Concomitant compelling indication to cardiothoracic surgery (eg severe MR) Absolute contraindications to antiplatelet therapy Previous failed PCI attempts (especially LAD) Multivessel CTO or CTO involving proximal-mid LAD Very high SYNTAX score

31. www.metcardio.org LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

32. www.metcardio.org CAN WE CAN DO WHATEVER THE SURGEON DOES?

33. www.metcardio.org CAN YOU DO IT? 85-year-old with non-STEMI, true trifurcational unprotected LM, concomitant MVD, high surgical risk and LVEF 45% 85-year-old ♂ with non-STEMI, true trifurcational unprotected LM, concomitant MVD, high surgical risk and LVEF 45%

34. www.metcardio.org ACTUALLY, IT CAN BE DONE, BUT SHOULD I DO IT? BEFORE PCI AFTER PCI WITH 4 STENTS Sheiban et al, Catheter Cardiovasc Interv 2009

35. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005

36. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005 THE ROLE OF PCI APPARENTLY LIMITED IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rates

37. www.metcardio.org MY PCI MUST DOs Previous CABG (especially if LIMA already there) Prohibitive surgical risk (with compelling indication) FFR unmasks MVD as just SVD Ongoing STEACS with culprit lesion amenable to primary PCI Patients refuses CABG (?!) but provided patient and referring colleagues are consenting!

38. www.metcardio.org MY EQUIPOISE Non-bifurcational ULM with high surgical risk Multivessel but focal disease with only A-B2 lesions, or non-challenging C lesions Good LV function Very young or very old Depending also on need for and likelihood of completeness of revascularization but still provided patient and referring colleagues are consenting!

39. www.metcardio.org TAKE HOME MESSAGES

40. www.metcardio.org MY PRACTICAL FLOWCHART

41. www.metcardio.org MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI

42. www.metcardio.org MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features

43. www.metcardio.org MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features Risk-benefit balance fine for PCI, but CABG can still be appropriate and thus should be discussed with patient and family Protected LM or 2VD with any of these “favorable” features : Ostial LAD ok Lack of diffuse disease No true bifurcations No CTO No diabetes Ongoing STEACS

44. www.metcardio.org MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features Risk-benefit balance fine for PCI, but CABG can still be appropriate and thus should be discussed with patient and family Protected LM or 2VD with any of these “favorable” features : Ostial LAD ok Lack of diffuse disease No true bifurcations No CTO No diabetes Ongoing STEACS PCI recommended (CABG should be considered only for proximal LAD) 1VD without other surgical indications

45. www.metcardio.org A. 1 ST STEP IN CRISIS MANAGEMENT IS PREVENTING IT: FOLLOW GUIDELINES UNLESS YOU ARE JUSTIFIED…

46. www.metcardio.org B. COLLABORATIVE DECISON-MAKING IN ALL BUT CLEAR-CUT CASES: INVOLVE OTHER INTERVENTIONAL COLLEAGUES, NON-INVASIVE CARDIOLOGISTS, AND SURGEONS

47. www.metcardio.org C. NEVER FORCE TOO MUCH… EITHER INDICATIONS, DEVICES, TECHNIQUES, OR ANCILLARY THERAPY (E.G. ANTI-THROMBOTIC RX)

48. www.metcardio.org Thank you for your attention For any correspondence: gbiondizoccai@gmail.com For these and further slides on these topics feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html gbiondizoccai@gmail.com http://www.metcardio.org/slides.html